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Differential Diagnosis
Cardiologic orthostatic HTN, arrhythmia,
CAD, etc.
Neurologic Acoustic neuroma, TIA,
stroke, Parkinson's, neuropathy, Migraine
Hematologic Anemia
Psychological Anxiety, panic
Metabolic/Endocrine Hypothyroidism Menopause
Orthopedic Cervical disk disease Lower extremity arthritis
Geriatric Proprioception Center of balance
Pharmacologic Polypharmacy Side effects
Dizziness– caused by many, many conditions
Differential Diagnosis
Vertigo (a false impression of movement)
Peripheral (otologic)
Benign Paroxysmal Positional Vertigo (BPPV)
Meniere’s Disease
Acute Labyrinthitis / Vestibular Neuronitis
Central (Neurologic)
MS, Migraine HA’s, benign intracranial hypertension
BPPV (Benign Paroxysmal Positional Vertigo)
• Intermittent vertigo which lasts
less than a minute, usually 10-
15 seconds
•Provoked by supine head
movements to the right or left
•Better when holding head still
•Caused by displaced otoliths in
the semicircular canals
•Positive Dix-Hallpike maneuver
•Treated with Epley maneuvers
Meniere’s Disease •A disorder of increased endolymphatic fluid pressure •Classic Triad-
Episodic SNHL, Vertigo x hours, and Roaring Tinnitus
•Low-frequency SNHL, ascending, and usually unilateral. •Treatment:
•Diuretics •Low sodium diet •Anti-vertigo medication •Surgery (to prevent vertigo)
•Surgical options include: •Endolymphatic sac decompression •Gentamicin injection •Labyrinthectomy
Labyrinthitis Infection or inflammation of the
inner ear. Vertigo is severe, lasts 24-72
hours, is disabling.
Vertigo subsides and the patient will have several weeks of imbalance
Treat acute vertigo with meclizine or diazepam
Treat chronic imbalance with physical therapy
If accompanied with sudden SNHL, treat with high dose prednisone
Vertigo Recap
BPPV- lasts seconds, head movements, no hearing loss
Meniere’s- lasts several hours, associated hearing loss, tinnitus, ear fullness
Labyrinthitis- lasts 1-3 days, gradual recovery with or without hearing loss
Sample PANRE question #4
Axel Rosenthal, age 43 presents with a complaint of loss of hearing in his right ear. Tuning fork tests revealed that air conduction is greater than bone conduction bilaterally. The Weber test lateralized to the left. What is the probable diagnosis? a. Right sided conductive hearing loss b. Right sided sensorineural hearing loss c. Left sided conductive hearing loss d. Left sided sensorineural hearing loss e. The patient has normal hearing
Sample PANRE question #5
Pat Benicar is a 75 year old female who presents with momentary room-spinning vertigo which occurs whenever she looks up or rolls over in bed. She denies hearing loss, tinnitus, and ear fullness. What is the appropriate treatment? a. Low salt diet, 1500-2000mg per day. b. Meclizine 25mg TID c. Prednisone, high dose x 12 days d. Epley Maneuvers e. Amoxicillin 500mg TID
Sample PANRE question #6 Gareth Brooks is a 54 year old man who presents for an evaluation of vertigo. Every few weeks, the patient will experience severe vertigo associated with ringing in the left ear and decreased hearing. What is the most appropriate first treatment for this condition? a. Epley maneuvers b. Meclizine 25mg three times a day c. CT brain with contrast d. Initiate a low salt diet e. Start the patient on amlodipine 10mg daily
RHINOLOGY
Epistaxis
Anterior- Kiesselbach’s plexus
Posterior- Woodruff’s plexus
Local risk factors Digital manipulation Septal deviation Inflammation
(allergies, infection)
Cold dry air Foreign body Juvenile angiofibroma Septal perforation Drug use
Nasal steroids Illicit drugs
Systemic Causes of Epistaxis
Systemic Causes of Epistaxis
Clotting Disorder
Hypertension
Leukemia
Liver disease
Medication (aspirin, plavix, coumadin)
Thrombocytopenia
Wegener’s Granulomatosis
Epistaxis
Treatment
Manual compression
Afrin
Cautery
Anterior/Posterior Packing
Surgical
Arterial Ligation
Embolization
Cauterization
RHINITIS
Allergic Rhinitis
IgE mediated reaction causing mast cells and basophils to release histamine, leukotriene, serotonin, and prostaglandins
Common allergens: Grass/Tree pollen, mold, dust, dander
This causes inflammation of the nasal mucosa. Nasal congestion
Rhinorrhea
Sneezing
Itching
Watery eyes
Allergic Shiner
Allergic Rhinitis
Treatment
Avoidance of allergens Nasal Saline lavage ------- > Nasal steroids
(fluticasone, mometasone, budesonide)
Antihistamines 2nd generation (fexofenadine, cetirizine, loratadine) Topical
nasal: (azelastine) eye: (olopatadine, azelastine)
Leukotriene inhibitor (monteleukast) Immunotherapy (allergy shots)
Nasal Polyposis
Seen with chronic rhinosinusitis, Samter’s Triad, and cystic fibrosis
Treat allergies
Nasal steroids
Systemic steroids
Surgical if obstructive, frequent infections, bony destruction
Vasomotor (Non-Allergic) Rhinitis Similar to allergic rhinitis, but caused by non-
allergy mediated inflammation due to irritation of nasal mucosa Temperature
Exercise
Foreign body
Fumes
Food
Medication
Rhinitis Medicamentosa
Drug induced rhinitis caused by overuse of topical decongestants (phenylephrine, oxymetazaline)
Rebound congestion
Treatment: STOP using the spray May substitute nasal steroids or antihistamine
Afrin taper
Prednisone taper
Viral Rhinitis Upper respiratory tract infection caused by adenovirus,
parainfluenza, corona virus, rhinovirus (and many more).
Symptoms usually last <7 days Sore throat Nasal congestion Rhinorrhea (may be yellow/green) Fever Cough (may be productive) Malaise Fatigue
Treatment: Supportive and time. OTC antihistamines, decongestants, mucolytics, fluids, ibuprofen, acetaminophen, rest.
SINUSITIS
Acute Bacterial Rhinosinusitis ABRS Signs and Symptoms
Persistent Symptoms (>10 days)
Localized Facial Pain
Upper Tooth Pain
Purulent nasal discharge
Nasal congestion
Severe Sx (3-4 days):
Fever >102 AND Purulent discharge OR
Facial pain
Double Sickening (3-4 days)
New onset of headache, fever, nasal d/c following viral URI which was improving after 5-6 days
Acute Sinusitis
Primary Treatment Empiric Antibiotics
Pathogens Strep. pneumo, H. flu, M. catarrhalis, Staph. aureus
1st Line (7-10 days adults, 10-14 days children)
Amoxicillin-clavulanate (Augmentin)
2nd Line (10-14 days) High dose amox/clav (2g BID or 90mg/kg/day BID) Cephalosporins (Cefdinir) Macrolides (clarithromycin, azithromycin) Sulfa (SMX/TMP) Doxycyline Quinolones (levofloxacin, moxifloxacin) Clindamycin
Chronic Sinusitis
Sinusitis for >12 weeks
Pathogens • Same as acute (S. pneumo, H. flu, M. cat., S. aureus) • Klebsiella, Pseudomonas, Proteus, Enterobacter,
MRSA • Consider anaerobic and fungal etiologies • Consider antibiotic resistance as cause
• Culture and sensitivity
• Consider structural abnormality: (non-contrasted CT Sinus) obtained after appropriate antibiotics
Sinus CT
Nasal Foreign Body
•Seen often in pediatrics •Consider if patient has foul nasal odor, chronic nasal discharge, nasal obstruction, sinusitis
•Chronic foreign bodies can cause pressure ulcers, infection, abscess
•Once removed, treat with antibiotics if signs of infection are present
Sample PANRE Question #7 Small E. Biggs is one of your frequent patients who is Notorious for asking for antibiotics whenever he is sick. He complains of an itchy runny nose, nasal congestion, cough and post-nasal drip. His symptoms have been present for 2 months. What is the most effective medication for this patient? a. Two pack of azithromycin 250mg b. Diphenhydramine 25mg c. Moxifloxacin 400mg a day d. Guaifenisen/dextromethorphan elixir e. Fluticasone nasal spray
PHARYNGITIS
Pharyngitis
Differential Diagnosis Post-nasal drip
Viral pharyngitis
Group A strep
Tonsillitis
Mononucleosis
Peritonsillar abscess
Cancer
HIV
Rare: gonorrhea, HSV
Viral Pharyngitis Pathogens
adenovirus, coronavirus, rhinovirus, influenza, parainfluenza, coxsackievirus
Self-limiting illness
Symptoms Erythema Edema Dysphagia Pain Fever Lymphadenopathy Upper respiratory illness symptoms
Resolves in 3-7 days Treat with OTC supportive meds
Strep Pharyngitis •Signs and Symptoms
•Sore throat •Dysphagia and Odynophagia •Erythema (w/ or w/o exudate) •Airway obstructive symptoms •Tender lymphadenopathy •Fever and malaise
•Only a culture can distinguish between viral tonsillitis and GABHS
•Rapid Strep Test •If negative, 24 hour culture
•Treat initially x 10 days
•1st Line: PenVK, Bicillin injection, Amoxicillin, Amox/clav •2nd Line: 1st gen cephalosporin (not if PCN allergy), clindamycin, azithromycin , Quinolone
Acute Tonsillitis
Bacterial (Usually GABHS) 15-30%
Viral EBV, CMV, HSV, adenovirus
Symptoms: pain, odynophagia, lymph nodes, fever
Treat: If bacterial, antibiotics. If viral supportive
Peritonsillar Abscess A collection of mucopurulent material in the
peritonsillar space
Often follows tonsillitis
Signs/Symptoms “Hot potato” voice Severe throat pain and dysphagia Inability to open jaw (trismus) Asymmetric swelling of soft palate Uvula deviation Copious salivation Fever, severe malaise
Peritonsillar Abscess
Treatment
Incision and Drainage
Antibiotics with anaerobic coverage
Amox/clav
Clindamycin
Mononucleosis
Pathogens EBV- Epstein Barr Virus CMV- Cytomegalovirus
Most mono patients were asymptomatic
Signs/Symptoms Fatigue Malaise Severe sore throat with tonsillar edema/erythema/exudate Lymphadenopathy Hepatosplenomegaly
Labs: Monospot (heterophile antibody test) CBC diff may show atypical lymphocytes
Treatment: OTC, pain control, consider steroids, avoid contact sports, seatbelt counseling
Parotitis/Sialadenitis
Painful swelling of parotid/salivary gland Can often express pus
from the parotid duct (Stensen duct)
Bacterial- usually staph Rarely: extrapulmonary TB
Viral- Mumps Treat with antibiotics,
sialagogues and warm compresses
Sialolithiasis Salivary duct calculus
Most commonly located at the submandibular (Wharton’s) duct.
Intense swelling of the salivary gland with salivation
Symptoms subside between meals
Treat with hydration, warm compresses, sialagogues.
If not better, may need surgical removal.
Sample PANRE QUESTION #8 Will I. Amherst is a 40 year old male who is seen on an urgent work-in for “sore throat” for the past 1 day. Upon exam he appears ill, is sitting uncomfortably with his neck extended. He speaks with a deep muffled voice. Upon exam, he is febrile, has trismus. His right soft palate is bulging, causing the uvula to shift past mid-line. The most likely diagnosis is: a. Acute mononucleosis b. Acute streptococcal pharyngitis c. Acute peritonsillar abscess d. Viral pharyngitis e. Squamous cell carcinoma of the right tonsil
ORAL TUMORS AND LESIONS
Oral Candidiasis Candida albicans
Usually when host flora is altered Antibiotics Steroid inhalers Immunocompromised
Signs: Erythematous mucosa with white satellite
lesions
Treat with antifungals Oral Nystatin solution
5cc swish and swallow QID
Fluconazole 200mg day 1, 100mg po day 2-5
Squamous Papilloma
Caused by Human papilloma virus (HPV)
Has the potential to become squamous cell carcinoma
Excisional biopsy is recommended
Often return despite biopsy
Leukoplakia
• Precancerous white plaque on a mucous membrane
• Can have different levels of dysplasia • Mild/Moderate/Severe
• Biopsy to confirm benign finding and stratify risk based on dysplasia
• Recommend routine monitoring • Smoking cessation
Aphthous Ulcers
•Idiopathic ulcerations of mucous membranes •Benign and self limiting •Very painful, lasting 10-14 days
Oral Herpes Simplex Caused by herpes simplex
virus. Very contagious.
Painful grouped vesicles, located outside the oral cavity.
Will crust over after 3-4 days
Symptoms usually last 2 weeks.
Treat with antivirals within 72 hours of symptoms (oral or topical)
Squamous Cell Carcinoma
Posterior Pharyngeal Wall Lateral Surface of Tongue
HOARSENESS
Hoarseness Duration of symptoms
Acute or chronic
Associated: sore throat, dysphagia, cough, hemoptysis, reflux, heartburn, allergies
Occupation (teacher, singer, phone operator)
Smoking and alcohol
Recent surgery
Thoracic Surgery
Hoarseness Differential Diagnosis
Acute but benign Infectious Laryngitis
(viral, bacterial, or fungal) Recent Intubation
Acute and severe Vocal Fold Paralysis Vocal Cord Hemorrhage
Chronic and benign Allergic Post-Nasal Drip LPR/GERD Inflammation caused by irritants (smoking) Vocal Abuse Vocal Nodules, cysts, papilloma, and Polyps
Chronic and severe Cancer
Acute Laryngitis
Usually self-limiting
Can be caused by viral infection, vocal misuse, or exposure to noxious agents
Treat with voice rest and fluids
Smoking cessation a must
Steroids and antihistamines not indicated
Normal Larynx Acute Laryngitis
Squamous Cell Carcinoma of the Larynx
Risks include Tobacco and ETOH
Usually very hoarse Associated symptoms
Throat pain Dysphagia/Odynophagia Weight Loss Ear pain Hemoptysis
Treated with a combination of modalities: Surgery, chemo, XRT
Sample PANRE question #9 Johnny Beck is a 75 year old man who complains of hoarseness and ear pain for the past 3 months. Associated symptoms includes pain when swallowing. What other finding would you expect to find on examination? a. Axillary lymphadenopathy b. 25 pound weight gain compared with his last visit c. Bulging right tympanic membrane d. Normal laryngoscopy exam e. Exophytic lesion on left true vocal cord
QUESTIONS?